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Coma from the Health Food Store: Interaction between Kava and Alprazolam
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TO THE EDITOR:
Millions of Americans use drugs sold in health food stores, yet most of these agents are unregulated. The potential for drug interactions is great. We report an interaction between kava and alprazolam that caused a semicomatose state.
A 54-year-old man was hospitalized at our center in a lethargic and disoriented state. His medications included alprazolam, cimetidine, and terazosin. His vital signs and results of laboratory studies were normal. His alcohol level was negative, and a drug screen was positive for benzodiazepines. He became more alert after several hours and stated that he had been taking a “natural tranquilizer” called kava for the past 3 days, bought from a local health food store. He denied overdosing on the kava or alprazolam.
The kava plant (Piper methysticum) is a perennial shrub belonging to the Piperaceae family [1]. The plant is indigenous to Oceania and is used widely in the South Pacific for its intoxicating effects [1]. Kava is marketed as a mild anxiolytic in European countries. In the United States, kava is sold in health food stores as a natural alternative to antianxiety drugs and sleeping pills.
The active component of kava belongs to a group called α-pyrones and is present in the root extract [2]. In a 1992 Australian study, Davies and colleagues [3] investigated the neuropharmacologic interactions of α-pyrones with central nervous system receptors and found weak effects on γ-amino butyric acid (GABA) or benzodiazepine receptors in vitro. Their findings were verified in a 1994 German study by Jussofie and associates [4] that also showed synergism between α-pyrones and other GABA-active sedatives.
Pharmacologic studies indicate additive effects between kava α-pyrones, pentobarbital, and pregnane steroids [4]. These investigational studies suggest that kava might have additive effects with benzodiazepines, given that they act on the same receptor and on the same areas of the central nervous system with increased GABA receptors [4]. We believe that these findings may explain the mechanism governing the possible interaction between kava and alprazolam.
This report of a possible drug interaction between kava α-pyrones and a benzodiazepine (alprazolam) signals the potential for dangerous interactions between kava and prescription drugs. The growing popularity of kava increases the danger.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
